Provider Demographics
NPI:1437538279
Name:PROUDAN, NIKOLETTA
Entity Type:Individual
Prefix:
First Name:NIKOLETTA
Middle Name:
Last Name:PROUDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19251 MACK AVE
Mailing Address - Street 2:STE 333
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2898
Mailing Address - Country:US
Mailing Address - Phone:412-359-3166
Mailing Address - Fax:
Practice Address - Street 1:320 E NORTH AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15212-4756
Practice Address - Country:US
Practice Address - Phone:412-359-3166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-26
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101025518207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty